Surgical Treatment of Osteomyelitis

REOrthopaedics, Inc., San Diego, CA, USA.
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 01/2011; 127 Suppl 1(1):190S-204S. DOI: 10.1097/PRS.0b013e3182025070
Source: PubMed

ABSTRACT Chronic osteomyelitis is refractory to nonsurgical treatment due to a resilient, infective nidus that harbors sessile, matrix-protected pathogens bound to substrate surfaces within the wound. Curative treatment mandates physical (surgical) removal of the biofilm colony, adjunctive use of antibiotics to eliminate residual phenotypes, and efforts to optimize the host response throughout therapy. Patient selection, therapeutic options, and the treatment format are determined by the Cierny/Mader staging system, while reconstruction is governed by the integrity/stability of the affected bone(s) and quality/quantity parameters of the soft-tissue envelope.

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    ABSTRACT: Background: Chronic osteomyelitis continues to be an intractable disease in orthopaedic surgery. Systemic antibiotics and debridement are currently the therapeutic mainstays. Calcium sulphate impregnated with antibiotics is commonly used to eradicate bone infection although there are few reports of its use. Methods: We treated 14 patients with chronic osteomyelitis using surgical debridement, a myocutaneous flap, systemic antibiotics, and vancomycin-loaded calcium sulphate, 12 males and 2 females, with an average age of 47 years (range: 17 to 65 years). In our study, 200 mg to 1000 mg of vancomycin was mixed with 5 cc of calcium sulphate and administered locally at the time of surgery. Tissue cultures were also taken at the same time. Vancomycin levels were determined in the drainage fluid after surgery. Fourteen patients with chronic osteomyelitis of the tibia, calcaneus, or ankle were treated for duration of two years and two months. The location and size of the infection was recorded. Subsequently, the patients were followed up clinically. Results: Satisfactory results were achieved in all patients. All cultures finally showed no growth, all wounds healed, and bone healing in 4 to 12 months. The lowest dose of vancomycin used was 200 mg and was associated with drain fluid concentrations of vancomycin that is much higher than the minimum inhibitory concentration (MIC) of treated bacteria. Medical imaging based on X-ray was performed pre- and post-surgery to evaluate surgical success. Conclusions: A myocutaneous flap that is combined with the 200 mg vancomycin-loaded calcium sulphate was an effective treatment for tibia and calcaneus osteomyelitis less than 4 cm in size.
    Journal of Medical Imaging and Health Informatics 02/2015; 5(1). DOI:10.1166/jmihi.2015.1362 · 0.62 Impact Factor
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    ABSTRACT: Wide resection of infected bone improves the odds of achieving remission of infection in patients with chronic osteomyelitis. Aggressive debridement is followed by the creation of large bone defects. The use of antibiotic-impregnated PMMA spacers, as a customized dead space management tool, has grown in popularity. In addition to certain biological advantages, the spacer offers a therapeutic benefit by serving as a vehicle for delivery of local adjuvant antibiotics. In this study, we investigate the efficacy of physician-directed antibiotic-impregnated PMMA spacers in achieving remission of chronic tibial osteomyelitis. This retrospective case series involves eight patients with chronic osteomyelitis of the tibial diaphysis managed with bone transport through an induced membrane using circular external fixation. All patients were treated according to a standardized treatment protocol. A review of the anatomical nature of the disease, the physiological status of the host and the outcome of treatment in terms of remission of infection, time to union and the complications that occurred was carried out. Seven patients, with a mean bone defect of 7 cm (range 5-8 cm), were included in the study. At a mean follow-up of 28 months (range 18-45 months), clinical eradication of osteomyelitis was achieved in all patients without the need for further reoperation. The mean total external fixation time was 77 weeks (range 52-104 weeks), which equated to a mean external fixation index of 81 days/cm (range 45-107). Failure of the skeletal reconstruction occurred in one patient who was not prepared to continue with further reconstructive surgery and requested amputation. Four major and four minor complications occurred. The temporary insertion of antibiotic-impregnated PMMA appears to be a useful dead space management technique in the treatment of post-infective tibial bone defects. Although the technique does not appear to offer an advantage in terms of the external fixation index, it may serve as a useful adjunct in order to achieve resolution of infection.
    Strategies in Trauma and Limb Reconstruction 04/2015; DOI:10.1007/s11751-015-0221-7
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    ABSTRACT: Over the past few decades considerable progress has been made in terms of our ability to reconstruct postinfective soft tissue and bone defects. Soft tissue reconstruction is not always required and it is frequently possible to achieve a tension-free closure of well-perfused tissue following debridement. It is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement. In cases were debridement has resulted in tissue loss, muscle or musculocutaneous flaps appear to be superior to random-pattern flaps in achieving resolution of infection. The management of bone defects is dependent on several factors including the host’s physiological status, the size of the defect, duration of the defect, quality of the surrounding soft tissue, the presence of deformity, joint contracture/instability or limb length discrepancy, as well as the experience of the surgeon. Surgery remains the mainstay of treatment when a curative treatment strategy is selected. As is the case with chemotherapy for bone tumours, antibiotic therapy fulfils an adjuvant role in curative management strategies. The choice of antibiotic, in this setting, remains a very difficult one and there are many problems with the interpretation of ‘cure rate’ data. The controversy surrounding the optimal duration and route of antibiotic therapy has not been resolved. The second role of antibiotics in the management of chronic osteomyelitis is disease suppression as part of a palliative treatment strategy. Further studies are required to clarify which patients may successfully be treated with antibiotics alone.


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